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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION I^ J <br /> P,O, BOX 368, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 r l(J I <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS MTUCATION IS MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT <br /> TITLE,CHAPTER 9-1110.3/� �AND THE STANDARDS OF SAN JOAQUIN COUNTY NBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRE66IOR�APNI V��O / !V JQ� `��/e�/� ��, C(ry �-0 LOT SIZE ` <br /> OWNER'S NAME /IA.CANL2 l.�.IR-� ADDRESS!JJR``V- -/,A`- // / U RHONE //��� <br /> CONTRACTOR_��/11"s�'U �ADDRESSIZ� Z-CdA-C(' L / L UCO ! �' RHONE _.( LcC� % <br /> SUBCONTRACTOR ADDRESS UCI PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAMIADDITION DESTRUCTION ❑ <br /> IRO SEPTIC SYSTEM PERMITTED IF NBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW 1 1 HOW MAMY <br /> Apdiwtlon I <br /> INSTALLATION WILL SERVE: RESIDENCE�OMMERCIAL 11 OTHER <br /> OTHER ❑ <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOOM$: 3 NUMBER OF EMPLOYEES: <br /> ER OF SOIL TO A DEPTH OF 3 FEET: K i� /SUMP S IL CHARACTEF '/ �A'✓�!-C WATER TABLE DEPTH <br /> CCC,,,..(((..���p TANK/ORFA6E TRAP ❑TYPEIMF - St%�H CAPACITY r/�E�C� NO.COMPARTMENT .� <br /> PKG TREATMENT RANT ❑ DISTANCE TO NEAREST: WELL 1G /0 FOUNDATION 1� / PROPERTY LINE /d)C , <br /> LIFT STATION❑c MSIZE TYPE OA^FJMMP <br /> / Y(SAND OIL SEPARATOR(ENCLOSED SYSTEM( 1 <br /> LFACMNO LINE �NO.i LENGTH OF LIN Eeh`Y LI( ' -,-, J DISTANCE TO NEAREST:WELLIOU /yFOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED 0 WIDTH LENGTH DEPTH�I DISTANCE TO NEAREST:WELL. PROPERTY LINE A1_A <br /> SEEPAGE RT$ YLI.OEPTH �S/ 612E�T NUMBER --� DISTANCE TO NEAREST:WELLL�FOUNDAT0IN PROPERTY UNE <br /> sumps ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> DISPOSAL BONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE- <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR <br /> SUB-CONT IRO SIGNATURE CERTIFI TME FOLLOW( . -ICERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WOPKM '6 CO PFI 6ATION LAWS OF IFOflNI TME ApR1CANT MWi CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWINGLBEELLLOW. <br /> SIGNED TITLE: DATE' <br /> \_ ROT PIAN(DRAW TO SCALE)SCALE 'le <br /> 1. NAMES OF STREETS OR ROADS NEA EST OR BOUNDING THE PROPERTY, 4. LOCATON OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH D NSIONB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> 1464,.'-4-r-� -pxXs:z 4 fa Ir-A 4-- <br /> o: <br /> YIUrIENT <br /> BF <br /> nirn <br /> SPR 20 <br /> SAN JOAQUIN COUNTY <br /> t I PUBLIC HEALTH SERVICES <br /> EMENTA: TH DNISIM <br /> o _ Z <br /> 6/ <br />